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Long-Term Outcomes After Medical and Invasive Treatment in Patients With Hypertrophic Cardiomyopathy | Journal Scan
Study Questions:
What are the long-term outcomes (all-cause mortality and sudden cardiac death [SCD]) after medical therapy, alcohol septal ablation, and myectomy in patients with hypertrophic cardiomyopathy (HCM)?
Methods:
A cohort of 1,047 consecutive patients with HCM (mean age 52 ± 16 years, 61% men) from three tertiary referral centers was evaluated. Of these, 690 patients (66%) had left ventricular (LV) outflow tract gradients ≥30 mm Hg, of whom 124 (12%) were treated medically, 316 (30%) underwent alcohol septal ablation, and 250 (24%) underwent myectomy. Primary endpoints were all-cause mortality and SCD.
Results:
The mean follow-up period was 7.6 ± 5.3 years. Ten-year survival was similar in medically treated patients (84%), patients who underwent alcohol septal ablation (82%), myectomy patients (85%), and patients with nonobstructive HCM (85%, log-rank p = 0.50). The annual rate of SCD was low after invasive therapy: 1.0%/year in the alcohol ablation group and 0.8%/year in the myectomy group. Multivariate analysis demonstrated that the risk for SCD was lower after myectomy compared with the alcohol ablation group (hazard ratio 2.1, 95% confidence interval 1.0-4.4, p = 0.04) and the medical group (hazard ratio 2.3, 95% confidence interval 1.0-5.2, p = 0.04).
Conclusions:
Patients with obstructive HCM who are treated at referral centers for HCM care have good survival and low SCD risk, similar to that of patients with nonobstructive HCM. The SCD risk of patients after myectomy was lower than after alcohol septal ablation or in the medical group.
Perspective:
Medically refractory obstructive HCM can be treated either surgically or percutaneously. These data suggest that alcohol septal ablation is inferior to surgical myectomy in reducing the risk of sudden cardiac death among patients with HCM and LV outflow obstruction. Notably, though, not all patients with HCM ought to be treated with an invasive strategy. Both surgical myectomy (with or without mitral valve intervention) and alcohol septal ablation attempt to treat LV outflow obstruction, and there are specific indications for them (see Elliott PM, et al. Eur Heart J 2014;35:2733-79). Neither would be expected to treat symptoms due to LV diastolic dysfunction.
Keywords: Tertiary Care Centers, Cardiomyopathy, Hypertrophic, Death, Sudden, Cardiac, Catheter Ablation, Ventricular Outflow Obstruction, Heart Septum
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